Understanding the barriers and enablers for postgraduate medical trainees becoming simulation educators: a qualitative study.

INTRODUCTION : There is increasing evidence that Simulation-based learning (SBL) is an effective teaching method for healthcare professionals. However, SBL requires a large number of faculty to facilitate small group sessions. Like many other African contexts, Mbarara University of Science and Technology (MUST) in Uganda has large numbers of medical students, but limited resources, including limited simulation trained teaching faculty. Postgraduate medical trainees (PGs) are often involved in clinical teaching of undergraduates. To establish sustainable SBL in undergraduate medical education (UME), the support of PGs is crucial, making it critical to understand the enablers and barriers of PGs to become simulation educators. METHODS: We used purposive sampling and conducted in-depth interviews (IDIs) with the PGs, key informant interviews (KIIs) with university staff, and focus group discussions (FGDs) with the PGs in groups of 5-10 participants. Data collection tools were developed using the Consolidated framework for implementation research (CFIR) tool. Data were analyzed using the rigorous and accelerated data reduction (RADaR) technique. RESULTS: We conducted seven IDIs, seven KIIs and four focus group discussions. The barriers identified included: competing time demands, negative attitude towards transferability of simulation learning, inadequacy of medical simulation equipment, and that medical simulation facilitation is not integrated in the PGs curriculum. The enablers included: perceived benefits of medical simulation to medical students plus PGs and in-practice health personnel, favorable departmental attitude, enthusiasm of PGs to be simulation educators, and improved awareness of the duties of a simulation educator. Participants recommended sensitization of key stakeholders to simulation, training and motivation of PG educators, and evaluation of the impact of a medical simulation program that involves PGs as educators. CONCLUSION: In the context of a low resource setting with large undergraduate classes and limited faculty members, SBL can assist in clinical skill acquisition. Training of PGs as simulation educators should address perceived barriers and integration of SBL into UME. Involvement of departmental leadership and obtaining their approval is critical in the involvement of PGs as simulation educators.

Variation within the visually evoked neurovascular coupling response of the posterior cerebral artery is not influenced by age or sex.

Neurovascular coupling (NVC) is the temporal and spatial coordination between local neuronal activity and regional cerebral blood flow. The literature is unsettled on whether age and/or sex affect NVC, which may relate to differences in methodology and the quantification of NVC in small sample-sized studies. The aim of this study was to 1) determine the relative and combined contribution of age and sex to the variation observed across several distinct NVC metrics (n = 125, 21-66 yr; 41 males) and 2) present an approach for the comprehensive systematic assessment of the NVC response using transcranial Doppler ultrasound. NVC was measured as the relative change from baseline (absolute and percent change) assessing peak, mean, and total area under the curve (tAUC) of cerebral blood velocity through the posterior cerebral artery (PCAv) during intermittent photic stimulation. In addition, the NVC waveform was compartmentalized into distinct regions, acute (0-9 s), mid (10-19 s), and late (20-30 s), following the onset of photic stimulation. Hierarchical multiple regression modeling was used to determine the extent of variation within each NVC metric attributable to demographic differences in age and sex. After controlling for differences in baseline PCAv, the R2 data suggest that 1.6%, 6.1%, 1.1%, 3.4%, 2.5%, and 4.2% of the variance observed within mean, peak, tAUC, acute, mid, and late response magnitude is attributable to the combination of age and sex. Our study reveals that variability in NVC response magnitude is independent of age and sex in healthy human participants, aged 21-66 yr.NEW & NOTEWORTHY We assessed the variability within the neurovascular coupling response attributable to age and sex (n = 125, 21-66 yr; 41 male). Based on the assessment of posterior cerebral artery responses to visual stimulation, 0%-6% of the variance observed within several metrics of NVC response magnitude are attributable to the combination of age and sex. Therefore, observed differences between age groups and/or sexes are likely a result of other physiological factors.

Patient navigation programs in Alberta, Canada: an environmental scan.

BACKGROUND: Patient navigation is a complex intervention that has garnered substantial interest and investment across Canada. We conducted an environmental scan to understand the landscape of patient navigation programs within the health care system in Alberta, Canada. METHODS: We included patient navigation programs within Alberta Health Services (AHS) and Alberta's Primary Care Networks (PCNs). Key informants were asked in October 2016 to identify existing programs and their corresponding program contacts. These program contacts were invited to complete a telephone-based survey from October 2016 to July 2017, to provide program descriptions and eligibility criteria, and to identify gaps in navigation. Programs were included if they engaged patients on an individual basis, and either facilitated continuity of care or promoted patient and family empowerment. We tabulated results and calculated summary statistics for program characteristics. RESULTS: Ninety-five potentially eligible programs were identified by key informants. The response rate to the study survey was 73% (n = 69). After excluding programs not meeting inclusion criteria, we included a total of 58 programs in the study: 43 AHS programs and 15 PCN programs. Nearly all programs (93%, n = 54) delivered navigation via an individual acting as a navigator. A minority of programs also included nonnavigator components, such as Web-based resources (7%, n = 4) and process or structural changes to facilitate navigation (22%, n = 13). Certain patient subgroups were particularly well-served by patient navigation; these included patients with cancer, substance use disorders or mental health concerns, and pediatric patients. Gaps identified in navigation fell under 4 domains: awareness, resources, geographic distribution and integration. INTERPRETATION: Patient navigation programs are common and have extended beyond cancer care, from which the construct originated; however, gaps include a lack of awareness and inequitable access to the programs. These findings will be of interest to those developing and implementing patient navigation interventions in Alberta and other jurisdictions.

Prevalence of antimicrobial resistance genes and its association with restricted antimicrobial use in food-producing animals: a systematic review and meta-analysis.

BACKGROUND: There is ongoing debate regarding potential associations between restrictions of antimicrobial use and prevalence of antimicrobial resistance (AMR) in bacteria. OBJECTIVES: To summarize the effects of interventions reducing antimicrobial use in food-producing animals on the prevalence of AMR genes (ARGs) in bacteria from animals and humans. METHODS: We published a full systematic review of restrictions of antimicrobials in food-producing animals and their associations with AMR in bacteria. Herein, we focus on studies reporting on the association between restricted antimicrobial use and prevalence of ARGs. We used multilevel mixed-effects models and a semi-quantitative approach based on forest plots to summarize findings from studies. RESULTS: A positive effect of intervention [reduction in prevalence or number of ARGs in group(s) with restricted antimicrobial use] was reported from 29 studies for at least one ARG. We detected significant associations between a ban on avoparcin and diminished presence of the vanA gene in samples from animals and humans, whereas for the mecA gene, studies agreed on a positive effect of intervention in samples only from animals. Comparisons involving mcr-1, blaCTX-M, aadA2, vat(E), sul2, dfrA5, dfrA13, tet(E) and tet(P) indicated a reduced prevalence of genes in intervention groups. Conversely, no effects were detected for ß-lactamases other than blaCTX-M and the remaining tet genes. CONCLUSIONS: The available body of scientific evidence supported that restricted use of antimicrobials in food animals was associated with an either lower or equal presence of ARGs in bacteria, with effects dependent on ARG, host species and restricted drug.

Comparison of different approaches to antibiotic restriction in food-producing animals: stratified results from a systematic review and meta-analysis.

BACKGROUND: We have previously reported, in a systematic review of 181 studies, that restriction of antibiotic use in food-producing animals is associated with a reduction in antibiotic-resistant bacterial isolates. While informative, that report did not concretely specify whether different types of restriction are associated with differential effectiveness in reducing resistance. We undertook a sub-analysis of the systematic review to address this question. METHODS: We created a classification scheme of different approaches to antibiotic restriction: (1) complete restriction; (2) single antibiotic-class restriction; (3) single antibiotic restriction; (4) all non-therapeutic use restriction; (5) growth promoter and prophylaxis restriction; (6) growth promoter restriction and (7) other/undetermined. All studies in the original systematic review that were amenable to meta-analysis were included into this substudy and coded by intervention type. Meta-analyses were conducted using random effects models, stratified by intervention type. RESULTS: A total of 127 studies were included. The most frequently studied intervention type was complete restriction (n=51), followed by restriction of non-therapeutic (n=33) and growth promoter (n=19) indications. None examined growth promoter and prophylaxis restrictions together. Three and seven studies examined single antibiotic-class and single antibiotic restrictions, respectively; these two intervention types were not significantly associated with reductions in antibiotic resistance. Though complete restrictions were associated with a 15% reduction in antibiotic resistance, less prohibitive approaches also demonstrated reduction in antibiotic resistance of 9%-30%. CONCLUSION: Broad interventions that restrict global antibiotic use appear to be more effective in reducing antibiotic resistance compared with restrictions that narrowly target one specific antibiotic or antibiotic class. Importantly, interventions that allow for therapeutic antibiotic use appear similarly effective compared with those that restrict all uses of antibiotics, suggesting that complete bans are not necessary. These findings directly inform the creation of specific policies to restrict antibiotic use in food-producing animals.

Examination of unintended consequences of antibiotic use restrictions in food-producing animals: Sub-analysis of a systematic review.

Antimicrobial resistance is considered one of the greatest threats to global and public health today. The World Health Organization, the Food and Agriculture Organization, and the World Organisation for Animal Health, known as the Tripartite Collaboration, have called for urgent action. We have previously published a systematic review of 181 studies, demonstrating that interventions that restrict antibiotic use in food-producing animals are associated with a reduction in antibiotic resistant bacterial isolates in both animals and humans. What remains unknown, however, are whether (and what) unintended consequences may arise from such interventions. We therefore undertook a sub-analysis of the original review to address this research question. A total of 47 studies described potential consequences of antibiotic restrictions. There were no consistent trends to suggest clear harm. There may be increased bacterial contamination of food products, the clinical significance of which remains unclear. There is a need for rigorous evaluation of the unintended consequences of antibiotic restrictions in human health, food availability, and economics, given their possible widespread implications.

The Quest for Value in Canadian Healthcare: The Applied Value in Healthcare Framework.

The exponential rise in healthcare costs in developed nations has sharpened the need for greater "value" in healthcare. Porter's (2010) seminal work is one of the most cited definitions and equation for value-based care. The pursuit of greater value in our healthcare system is of paramount importance, yet translating value-based healthcare (VBHC) into a framework that can be effectively utilized in the Canadian system remains a challenge. To address this challenge, we propose that VBHC can be adapted to fit the Canadian healthcare system through (1) visionary leadership for and conceptualization of VBHC at the federal government level and (2) thoughtful application of VBHC at the provincial government level. Our applied value in healthcare framework serves as a platform from which VBHC initiatives, programs and outcome measures can be systematically organized and executed within provincial healthcare systems. This methodical approach could support both provincial ministries and their health systems in pursuit of VBHC and provide the basis for explicit measurement of VBHC success, thereby helping to address the pressing issue of sustainability of the Canadian healthcare system while optimizing patient-centred outcomes of care.

Turk Talk: human-machine hybrid virtual scenarios for professional education.

This article was migrated. The article was marked as recommended. Virtual scenarios provide a means for creating rich and complex online cases for health professional students to explore. However, the response options available to the learner are usually predefined, which limits the utility of virtual patients. Using artificial intelligence or natural language processing to accommodate such flexibility is expensive and hard to design. This project description lays out an alternative approach to making virtual scenarios more adaptable and interactive. Using OpenLabyrinth, an open-source educational research platform, we modified the interface and functionality to provide a human-computer hybrid interface, where a human facilitator can interact with learners from within the online case scenario. Using a design-based research approach, we have iteratively improved our cases, workflows and scripts and interface designs. The next step is testing this new functionality in a variety of situations. This report describes the pilot implementation of this pilot project. It includes the background, rationale, objectives, learning and educational designs, and implications for software development. The costs and time required to modify the software were much lower than anticipated. Facilitators managed text input from multiple concurrent learners. Learners noted a delay while waiting for the facilitator's response, but denied becoming frustrated. The implementation and use of this new technique seems promising for training and assessment purposes related to developing effective communication skills. This report also explores the provisional implications arising from the study so far.

Restricting the use of antibiotics in food-producing animals and its associations with antibiotic resistance in food-producing animals and human beings: a systematic review and meta-analysis.

BACKGROUND: Antibiotic use in human medicine, veterinary medicine, and agriculture has been linked to the rise of antibiotic resistance globally. We did a systematic review and meta-analysis to summarise the effect that interventions to reduce antibiotic use in food-producing animals have on the presence of antibiotic-resistant bacteria in animals and in humans. METHODS: On July 14, 2016, we searched electronic databases (Agricola, AGRIS, BIOSIS Previews, CAB Abstracts, MEDLINE, Embase, Global Index Medicus, ProQuest Dissertations, Science Citation Index) and the grey literature. The search was updated on Jan 27, 2017. Inclusion criteria were original studies that reported on interventions to reduce antibiotic use in food-producing animals and compared presence of antibiotic-resistant bacteria between intervention and comparator groups in animals or in human beings. We extracted data from included studies and did meta-analyses using random effects models. The main outcome assessed was the risk difference in the proportion of antibiotic-resistant bacteria. FINDINGS: A total of 181 studies met inclusion criteria. Of these, 179 (99%) described antibiotic resistance outcomes in animals, and 81 (45%) of these studies were included in the meta-analysis. 21 studies described antibiotic resistance outcomes in humans, and 13 (62%) of these studies were included in the meta-analysis. The pooled absolute risk reduction of the prevalence of antibiotic resistance in animals with interventions that restricted antibiotic use commonly ranged between 10 and 15% (total range 0-39), depending on the antibiotic class, sample type, and bacteria under assessment. Similarly, in the human studies, the pooled prevalence of antibiotic resistance reported was 24% lower in the intervention groups compared with control groups, with a stronger association seen for humans with direct contact with food-producing animals. INTERPRETATION: Interventions that restrict antibiotic use in food-producing animals are associated with a reduction in the presence of antibiotic-resistant bacteria in these animals. A smaller body of evidence suggests a similar association in the studied human populations, particularly those with direct exposure to food-producing animals. The implications for the general human population are less clear, given the low number of studies. The overall findings have directly informed the development of WHO guidelines on the use of antibiotics in food-producing animals. FUNDING: World Health Organization.

Patient safety principles in family medicine residency accreditation standards and curriculum objectives: Implications for primary care.

OBJECTIVE: To conduct a thematic analysis of the College of Family Physicians of Canada's (CFPC's) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. DESIGN: Thematic content analysis of the CFPC's Red Book accreditation standards and the Triple C curriculum. SETTING: Canada. MAIN OUTCOME MEASURES: Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. RESULTS: Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). CONCLUSION: Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice.

Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers.

BACKGROUND: Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers. METHODS: A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions. RESULTS: Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37%), including 272 of 512 nurses (53%), 153 of 484 internal medicine trainees (32%), and 43 of 260 attending physicians (17%). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making. CONCLUSIONS: Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.

Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians.

IMPORTANCE: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers. OBJECTIVE: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process. DESIGN, SETTING, AND PARTICIPANTS: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces. MAIN OUTCOMES AND MEASURES: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach. CONCLUSIONS AND RELEVANCE: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Measuring competence in central venous catheterization: a systematic-review.

OBJECTIVES: Central venous catheterization is a complex procedural skill. This study evaluates existing published tools on this procedure and systematically summarizes key competencies for the assessment of this technical skill. METHODS: Using a previously published meta-analysis search strategy, we conducted a systematic review of published assessment tools using the electronic databases PubMed, MEDLINE, Education Resource Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica, and Cochrane Central Register of Controlled Trials. Two independent investigators abstracted information on tool content and characteristics. RESULTS: Twenty-five studies were identified assessing a total of 147 items. Tools used for assessment at the bedside (clinical tools) had a higher % of items representing "preparation" and "infection control" than tools used for assessment using simulation (67 ± 26% vs. 32 ± 26%; p = 0.003 for "preparation" and 60 ± 41% vs. 11 ± 17%; p = 0.002 for "infection control", respectively). Simulation tools had a higher % of items on "procedural competence" than clinical tools (60 ± 36% vs. 17 ± 15%; p = 0.002). Items in the domains of "Team working" and "Communication and working with the patient" were frequently under-represented. CONCLUSION: This study presents a comprehensive review of existing checklist items for the assessment of central venous catheterization. Although many key competencies are currently assessed by existing published tools, some domains may be under-represented by select tools.

"Who writes what?" Using written comments in team-based assessment to better understand medical student performance: a mixed-methods study.

BACKGROUND: Observation of the performance of medical students in the clinical environment is a key part of assessment and learning. To date, few authors have examined written comments provided to students and considered what aspects of observed performance they represent. The aim of this study was to examine the quantity and quality of written comments provided to medical students by different assessors using a team-based model of assessment, and to determine the aspects of medical student performance on which different assessors provide comments. METHODS: Medical students on a 7-week General Surgery & Anesthesiology clerkship received written comments on 'Areas of Excellence' and 'Areas for Improvement' from physicians, residents, nurses, patients, peers and administrators. Mixed-methods were used to analyze the quality and quantity of comments provided and to generate a conceptual framework of observed student performance. RESULTS: 1,068 assessors and 127 peers provided 2,988 written comments for 127 students, a median of 188 words per student divided into 26 "Areas of Excellence" and 5 "Areas for Improvement". Physicians provided the most comments (918), followed by patients (692) and peers (586); administrators provided the fewest (91). The conceptual framework generated contained four major domains: 'Student as Physician-in-Training', 'Student as Learner', 'Student as Team Member', and 'Student as Person.' CONCLUSIONS: A wide range of observed medical student performance is recorded in written comments provided by members of the surgical healthcare team. Different groups of assessors provide comments on different aspects of student performance, suggesting that comments provided from a single viewpoint may potentially under-represent or overlook some areas of student performance. We hope that the framework presented here can serve as a basis to better understand what medical students do every day, and how they are perceived by those with whom they work.

Team-based assessment of medical students in a clinical clerkship is feasible and acceptable.

BACKGROUND: This study describes the development, implementation and evaluation of a team-based, multi-source method of assessment in which students on a clinical clerkship were provided with feedback on their performance as observed by physicians, residents, nurses, peers, patients and administrators. METHODS: The instrument was developed by reviewing existing assessment items and by obtaining input from assessors and students. Numerical data and written comments provided to students were collected, internal consistency was estimated and interviews and focus groups were used to determine acceptability to assessors and students. RESULTS: A total of 1068 assessors completed 3501 forms for 127 students. Internal consistency estimates for each assessment form were acceptable (Cronbach's alpha 0.856-0.948). Each student received an average of 188 words of written feedback divided into an average of 26 'Areas of Excellence' and 5 'Areas for Improvement'. Interviews revealed that the majority of students and assessors interviewed found the method acceptable. CONCLUSIONS: This study demonstrates that a team-based model of assessment based on the principles of multi-source feedback is a feasible and acceptable form of assessment for medical students learning in a clinical clerkship, and has some advantages over traditional preceptor-based assessment. Further studies will focus on the strengths and weaknesses of this novel assessment technique.